Sundowning — increased confusion, agitation, and behavioral difficulty in the late afternoon and evening — affects an estimated 20% of people with Alzheimer's. Understanding why it happens and what you can do during those hours separates reactive caregiving from skilled preventive care.
What Is Sundowning?
Sundowning (also called late-day confusion or sundowner's syndrome) refers to a pattern of increased confusion, anxiety, agitation, and behavioral symptoms that emerge or intensify in the late afternoon and evening hours — roughly between 3pm and 8pm — and typically improve or resolve later at night or in the morning.
What Sundowning Looks Like
- Increased confusion: Disorientation about time, place, and people that is markedly worse than morning baseline.
- Anxiety and restlessness: Inability to sit still, pacing, wringing hands, calling out repeatedly.
- Agitation or aggression: Irritability and combativeness that wasn't present in the morning.
- "I want to go home": A client who is home but is experiencing the emotional signal that something is wrong — expressed as wanting to go somewhere safe.
- Seeing things: Visual disturbances or hallucinations may intensify in lower light conditions.
- Following (shadowing): The client follows the caregiver from room to room, unable to tolerate being alone.
Prevention Strategies: During Your Shift
- Light therapy: Maximize bright natural light exposure during the morning and early afternoon. This is one of the most evidence-supported interventions.
- Protect the afternoon calm: Plan the most demanding care tasks (bathing, appointments) for the morning when the client is most alert. Keep afternoons lower-demand.
- Consistent routine: Predictable daily schedules reduce confusion that contributes to sundowning.
- Exercise in the morning: Physical activity earlier in the day, not the afternoon, to avoid overstimulation during the vulnerable afternoon window.
- Reduce stimulation in the afternoon: Lower TV volume, reduce the number of people present, create a calmer environment as the afternoon approaches.
- Limit caffeine and sugar: Particularly after noon — both can exacerbate afternoon restlessness.
Responding During a Sundowning Episode
Increase light
Turn on lights in the room as natural light fades. Brighter indoor lighting counteracts the disorientation that low light causes. This is one of the simplest and most effective in-the-moment interventions.
Familiar music
Playing calming, familiar music from the client's era can orient and soothe during sundowning episodes. Keep a playlist of their favorites accessible.
Gentle movement
A short, calm walk — inside or outside — often interrupts the agitation cycle. Movement provides sensory input that can reduce restlessness.
Comfort routine
A consistent pre-evening comfort routine — a warm decaf drink, a familiar activity, soft lighting — can become a calming anchor if done consistently over time.
When to Report Sundowning to the Nurse
- Is new — the client hasn't had this pattern before
- Is dramatically worsening — much more intense than previous episodes
- Includes new safety risks — wandering, aggression, falls
- Is not responding to any intervention you've tried
- Is accompanied by signs of a medical problem (fever, pain, incontinence changes)